Simulation: It’s about the Patient

marlon-lara-1421315-unsplashPhoto by Marlon Lara on Unsplash

Buoyed by the first standardized patient (SP) encounter in my previous blog post, I felt confident reaching for the patient chart on the door of the next examination room at the SIU School of Medicine standardized patient training.

Until I read the case file:

“Mr. Casey, aged 42, has received a letter after a regular blood donation. They have detected HIV/AIDS.

Conduct a history and physical diagnosis on the patient.”

Oh, boy.

I opened the door slowly.

Mr. Casey sat in a chair, head in his hands. He looked up when I walked into the room.

“Mr. Casey? Hello, my name is Anna. Can you tell me why you are here today?”

The emotional roller coaster ride this standardized patient took me on was incredible.

I believed his distress. I felt it, too. I became more anxious as the encounter went on. Unlike my examination of Mrs. Reynolds, Mr. Casey filled me with consternation.  Suddenly aware of scope of practice and medical advice, I wavered about providing him with correct information (no, HIV/AIDS is not a gay disease; you can contract HIV/AIDS through blood transfusions, exchange of bodily fluids, sexual intercourse) and not knowing the correct information to alleviate his fears (which medications he can take; whether he has HIV/AIDS or not, how long he can live with HIV/AIDS). Debates in my head played on a loop. I should take a detailed sexual history to determine infection – how do I do that? What kind of physical am I allowed to do with an SP? Can I counsel him? The whole time, the patient became more agitated.

I reached out and touched his arm.

“Can I get you anything? Some water, perhaps? A tissue?”

Mr. Casey looked up and around; he reached over and pulled a tissue from the box near him. For the rest of the session, Mr. Casey played with that tissue – wringing it, pulling at it, rolling it, wiping his nose. For the rest of the session, Mr. Casey did not make eye contact with me.

I felt inadequate and disturbed. Had 20 minutes not passed?

My eyes circled the room one last time. Was there any information in the room that could help me?

I bailed on Mr. Casey. I excused myself, saying that I was going to connect him with a counsellor and find out more about getting blood-work done.

*             *             *             *             *

One of the things we learned last week: never break simulation. Rule #2: see Rule #1. There are safety nets built into simulation. The SIU School of Medicine has a safe word that anyone can use to extricate themselves from a simulation: Irene. For example, you can refer to a patient file and say, “I see Dr. Irene Tardokas wrote you a prescription for…” and a member of the training team will intervene. This ensures comfort for all involved and keeps the spirit of the simulation as real as possible.

In encounters such as the one I had with Mr. Casey, a debrief is conducted with a medical student to safeguard against any triggers an exchange may cause. Some cases deal with sexual violence, and SPs have the appropriate bruises and swelling to make the experience as real as possible for the student. In our debriefs with students, they often referred to how they look for physical scars or indications on the skin for any possible clue of disease or condition.

The SIU School of Medicine also has information to train its SPs to mimic physical symptoms that (should) fool medical students. I worked extensively with a group of trainers and an SP to mimic a collapsed lung that would not be detected by a stethoscope. Drawing on personal experience once more, I helped an SP shuffle and present as a patient with Parkinson’s. All those years of ensuring my instructions were clear for language learners came in handy.

In a group of nurses, SP trainers, educators, and administrators, we quickly learned how to draw on each others’ strengths. One RN trained in emergency care shared photos of her moulage talents – the high-fidelity manikin had authentic-looking dog bites. A lot of learning took place through storytelling – an SP is never used as the patient who dies in a simulation – the trainers always use a manikin to reduce the amount of anxiety a medical student experiences in delivering terminal news to a patient, whereas the SP is used as a distraught family member. Each simulation is followed by a debrief with everyone – the medical student as well as the SPs – to ensure individuals have been supported through the process and offered additional support if needed.

file-3Manikin – Photo by Anna Bartosik

The SP trainers, as they watch simulations, become very knowledgeable about the SPs as well as the medical students who pass through the simulation labs. They know the strengths and weaknesses of the medical students. It is amazing how many details need to be considered (should the SP play sports? What kind of sports? If the medical student talks about hockey, does the SP know enough to engage in that conversation?) and how minuscule details get missed: a 72-year-old SP presenting with erectile dysfunction told a medical student he had sexual intercourse 8 times a week when asked about his sexual activity. It was the one detail in the scenario the trainers had forgotten to address in the case, so when the SP answered, he answered honestly. The trainers are also present for case development – they have a mental Filofax of SPs who present well with specific symptoms, as well as those who “would be perfect to play a parapalegic,” for example.

All the encounters I had with SPs last week impressed the need to have believable patients. These SPs take their roles and contribution to medical education seriously. By the end of the week, all of the participants in the training were requesting specific SPs we had encountered for our respective cases.

*             *             *             *             *

Mr. Casey had a chance to debrief with all of us. We were fascinated and frightened by his ability to convincingly portray a distraught patient. During our debrief, the SP formerly known as Mr. Casey talked about how he considers every detail of his attire and props – down to the display on his phone if he has to call a family member in a scenario. He was so method I observed him get into character in a scenario before the medical student entered the room.

Although he didn’t single out any encounter, he talked about how important the buy-in is for him when he plays a patient.

“When a student reaches out and touches me, especially if I’m an emotional patient: that has an impact on me. I work hard to make sure I’m believable. Knowing that I’m touchable as an AIDS patient means so much to me.”

Next post – developing a case.

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